Ricochet is the best place on the internet to discuss the issues of the day, either through commenting on posts or writing your own for our active and dynamic community in a fully moderated environment. In addition, the Ricochet Audio Network offers over 50 original podcasts with new episodes released every day.
I was a third-year medical student (otherwise known as a scut-monkey – responsible for every job in the hospital that no one else wants to do) when we had a 96-year-old woman come in with pneumonia. The resident in charge of me told me to get her old hospital records. I asked the patient if she’d ever been in the hospital, and she said that she had, just once, in this very hospital. Great, I thought – that makes it much easier. No records transfers. This was the early 1990s, and we still had paper charts, which were archived in the basement after six months. So I was hoping her hospitalization was recent.
I asked her when her hospitalization was. She answered, “When I was four years old. Maybe five. I really don’t remember it very well.” I just stared at her. That would be around the year 1897. Maybe 1898 or 1899. That won’t be on the front rack. It was 11 p.m. My hopes for sleep that night were fading fast. So I trudge down to the basement, walk past endless racks of charts, and start digging through boxes back by the heating and air equipment.
One advantage I had was that no one had disturbed these boxes in some time. So unlike the more recent charts, everything was about where you’d expect it to be. And sure enough, I found her chart. I sat down on a box and started reading.
She had gotten very sick very quickly, and her father had carried her into the hospital. She couldn’t walk. She had a fever of 104.5F, was barely conscious, and recoiled when the doctor touched her abdomen. They removed a gangrenous appendix that night and put in drains to help with the infection. There were no antibiotics available at that time.
She remained semi-conscious for days. The surgeon would check on her, and occasionally put in a new drain, sometimes did a sort of lavage, and each day he described exactly how she was doing and what his plan was. I felt like I was making rounds with him in real-time, even though he’d probably been dead for 75 years.
He did a great job. She was in the hospital for over three weeks, nearly dying twice. But eventually, she started eating again, and eventually went home. She walked out of the hospital, after being carried in a few weeks earlier.
And due to the skill of the surgeon and the nurses, despite what now looks like primitive equipment and techniques, I was now seeing this patient 90 years later, after she had had a wonderful life with children, grandchildren, and so on. Her surgeon was dead and gone, but she was not. Outstanding work, sir.
What I remember most clearly, though, was the chart. The entire chart for her hospitalization of over three weeks was one sheet of paper. Filled on one side, and about halfway down on the backside.
And I knew exactly what had happened, every step of the way.
Our charts now are sort of the opposite of that.
They are enormous. I’ll have a patient spend one night in the hospital for a routine CHF exacerbation, I’ll request records, and I’ll get 75 pages of, um, just all kinds of stuff. It’s incredible, really, how much data they can collect on one patient in 24 hours. But here’s the problem.
When I look at those records, what I really want to know is, what did the hospital doctor think was wrong, what did she do to treat it, and how does she think this is likely to go? What might go wrong? What should I be watching for?
The chart I get will include, on page 56, the name of the nurse who changed the patient’s sheets that morning. But it will not include the two or three sentences that I’m looking for. What happened exactly?
It’s like asking for a glass of water and getting thrown into the pool.
Paperless chart systems are designed to generate as much paperwork as possible as quickly as possible. Because in modern medicine, we get paid to produce paperwork, not to take care of sick people. Now, when I make rounds in the hospital, there are nurses up and down the halls working on their mobile PC units. It’s unusual to find a nurse with an actual patient. Because the patients don’t matter. But the documentation does. Thank you, Medicare.
One of the entries from the surgeon in 1898 was something like, “I changed the drain to a new site yesterday. Pt much worse today. I fear that may have been a mistake. We’ll see.” Or something like that.
That is very helpful. He’s telling you what he’s observing, and what he’s thinking. Which is very important. In fact, it’s all that really matters.
In today’s legal environment, such thinking is prohibited. Or at least, you keep it to yourself. Which means that honest communication between doctors has been banned, for all intents and purposes. So if I want to know what happened, I have to talk to the doctor personally, off the record, and ask, “Hey, Sarah, you sent an unstable CHF patient home on freakin’ Spironolactone in 24 hours? What’s up?” And she’ll explain. And it will probably make sense. Off the record. Then, and only then, will I know what’s going on.
So it’s like going back to before we had charts. The only way to get any real information is word of mouth. Like in the days before Sanskrit.
So charts work for Medicare reimbursement. Sort of. I guess.
But they don’t work for doctors. Or patients. Or nurses. They have become useless. Worse than useless. They distract nurses and doctors from what used to be the most important part of all this: The patient.
It makes me sad.
That’s why I’m a bleeding-heart conservative. Leftism is heartless. Big government is heartless. Centralized control is heartless. It always is. There is no other way.
I’m not heartless. That’s why I went into medicine to begin with.
I don’t fit in this system.
The system doesn’t care about my concerns, of course. It’s heartless.
My patients do care. But they don’t matter any more than I do.
In a leftist system, all that matters is leftism.
And leftism is heartless.Published in